Nine Steps for Standardizing Privileges in a Health System: What It Takes to Be Successful

Nine Steps for Standardizing Privileges in a Health System: What It Takes to Be Successful

Mar 21, 2019

Author: Wendy Crimp, BSN, MBA, CPHQ, Senior Consultant, Verity, A HealthStream Company


There are many reasons a health system should standardize privileges across all its medical staffs—improved program management, compliance with regulatory and accreditation requirements, alignment with contemporary clinical practice, and to assess and manage clinical competence. Many organizations avoid taking this step due to the difficulties involved, from varying clinical services and cultures, as well as competitors’ actions, to differing takes on specialization and incentives that don’t align.


Establishing a workable common platform for a project aimed at standardizing privileges is essential. Leaders should emphasize shared standards, which already exist in training, licensing, and peer-reviewed literature, as well as evidence-based practices that support improved care quality and patient safety. For widespread buy-in, all parties must understand the need for the project, especially how current privileging programs may not meet prevailing standards, creating serious risk management issues.


Here’s how a typical project to standardize privileges may proceed successfully:


1. Create Project Charter


The charter should be approved by every Medical Executive Committee (MEC) involved. It needs to create a mechanism for shared oversight and control and include participation at subspecialty and specialty levels as shared privilege delineations are developed and finalized. This charter should define:


  • Project Intent
  • Desired Future State
  • Methodology for Form Approval
  • Methodology for Addressing Dissenting Opinions
  • Transition Plan

2. Determine People Involved


Identify Project Manager, ideally with a clinical background and privileging training, and members of the Privileging Task Force, to provide project oversight and keep it moving. This small group, typically made up of the credentials chair from each hospital involved, will resolve disputes and differences of opinion.


3. Take Inventory of Delineations


Using current delineations by site, develop inventory for future delineations. Share information with the Privileging Task Force—members need to understand the current state and concur with plans.


4. Engage Practitioner Reviewers


Select practitioner leaders to participate at the subspecialty and specialty levels. Develop rules for participation, outlining the project and responsibilities, and allow prospects to decline to participate.


5. Draft Privilege Delineations


Use pre-populated best practice content to ease the burden on participating physicians. If format is standardized across all specialties, then required elements will consistently be addressed. Physician participants should edit content to fit the system environment and expectations.


6. Review Delineation Drafts


Complete first draft reviews and incorporate edits into second drafts. Third and fourth round drafts may be required for all forms to be approved. If project support is dedicated, all forms can be approved by the MEC in approximately 9 months.


7. Reinforce the Reason for this Project


Keep reinforcing the problems new delineations will solve for medical staffs. A best practice is to use “clinical activity reflective of the scope and complexity of the privileges requested” rather than requiring applicants to provide clinical activity for each and every item (or none at all). The organization can consolidate privileging of similar items and ease doubts about what is actually included in a delineation. This will achieve the goal of reflecting contemporary practice and eliminate duplication of effort for medical staff, physician leaders, and administrative staff.


8. Transition to New Privilege Forms


Initial applicants will receive new forms as they are approved. Develop conversion maps for each delineation and apply them to all existing privilege holders. These maps will determine which forms apply to applicants for renewal, aligned with reappointments’ timing. Set expectations by sharing information about the process to existing privilege holders.


9. Establish Ongoing Unified Privileging


Support continued alignment and standardization of privileging, now that the organization has centralized expertise and coordination. Regularly convene the Privileging Task Force or a shared Credentials Committee, moving forward. Eliminate duplication of effort in maintaining forms across multiple sites.

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